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J. Clin. Med. 2018, 7(8), 199; https://doi.org/10.3390/jcm7080199

Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline

1
Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy
2
Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France
3
Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France
4
Nephrology, Brotzu Hospital, 09100 Cagliari, Italy
5
Association ECHO, 44000 Nantes, France
6
Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France
7
Nefrologia, Ospedale di Trento, 38100 Trento, Italy
The authors contributed equally to this manuscript.
*
Author to whom correspondence should be addressed.
Received: 29 June 2018 / Revised: 21 July 2018 / Accepted: 1 August 2018 / Published: 3 August 2018
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Abstract

Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.
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Keywords: nephrology; health care; model of care; dialysis kidney transplantation; CKD; pre-dialysis care; prevention nephrology; health care; model of care; dialysis kidney transplantation; CKD; pre-dialysis care; prevention
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Piccoli, G.B.; Breuer, C.; Cabiddu, G.; Testa, A.; Jadeau, C.; Brunori, G. Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline. J. Clin. Med. 2018, 7, 199.

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